Cardiology
Expert discussions on heart failure, arrhythmias, interventional procedures, and cardiovascular risk management.
Recent Discussions
When would you consider initiation of low-dose aspirin for primary prevention and/or statin therapy in patients with acceptable bleeding risk and evidence of coronary artery calcification on prior CT chest imaging?
Several observational cohort studies show that persons with a CAC score >100 and who are at low bleeding risk, experience a net benefit with low-dose aspirin, with lower risk of MACE compared with bleeding. In the MESA study (Cainzos-Achirica and Nasir, PMID 32151147), among participants with a CAC>...
Would you consider adding an SGLT2 inhibitor to augment diuresis in patients with worsening renal function presenting with acute decompensated heart failure and AKI on CKD?
SGLT2 inhibitors can provide another avenue in providing the much-needed diuresis our decompensated patients have. AKI often accompanies this decompensation. SGLT2 inhibitors can be used safely at times with GFR> 25. I would consider adding it to my regimen of aggressive diuresis to provide aggressi...
What burden of PVCs/NSVT in an inpatient post-MI cardiomyopathy patient would prompt an EP study-guided ICD implantation prior to discharge?
This is an interesting scenario which is best addressed by the results of the MUSTT trial. In that study patients with ischemic cardiomyopathy who had ejection fraction of </=40% and manifested NSVT (3 beats to < 30 seconds) underwent EP study and if they were inducible for sustained VT then they we...
In what situations/patient population would you consider placing an implantable cardiac monitor in favor of external monitors for long-term dynamic monitoring of atrial fibrillation?
This is an excellent question and I think we need the remainder of the publication to make our best estimates (specifically Table 1 and the n for results, including % ablated - couldn't find online or any pictures of slide data on Twitter). The online MONITOR-AF late-breaking trial abstract is avail...
What is your approach to pacemaker lead thromboses in terms of threshold for lead extraction and initiation of systemic anticoagulation?
This is a question that often comes up. In general, most thrombi found on chronic pacing leads incidentally noted on an echo in our experience are not problematic. However, the bigger question is whether the mass noted is indeed a thrombus versus some vegetation related to an infection. In one publi...
What is your approach to counseling an octogenarian on the risks and benefits of LHC in the context of NSTEMI complicated by new-onset heart failure and AKI on CKD?
This is a complex though not uncommon clinical scenario to which my approach would depend on many factors beyond those provided in the vignette. Among these (not an exhaustive list and not necessarily in order of importance): Is this a type I or type II NSTEMI? Is there evidence of ongoing ischemia ...
What is your preferred method of lesion interrogation for intermediate left main coronary artery stenosis?
I typically use a multimodality approach including iFR or FFR (using typical cut offs) and IVUS using cutoff of MLA < 6.0 mm2.
How reliable is an exercise stress echo in the diagnosis of exercise-induced heart failure with preserved ejection fraction?
This is my understanding of HFpEF. It is a clinical diagnosis of exertional Dyspnea in patients with risk factors such as HTN, atherosclerosis and Hyperlipidemia, increased BMI, and inactivity. A new classification means stage A only risk factors, stage B has some organ dysfunction such as LVH, left...
In which situations do you preferentially use an MCOT in lieu of a standard event monitor?
In most situations where the concern for "actionable" arrhythmias is low (e.g., isolated palpitations, mild lightheadedness, AF burden, PVC burden, known persistent AF for assessment of rate control, etc.), I typically would use an extended 7-14 day Holter mostly for symptom-arrhythmia correlation s...
What is a reasonable amount of ventricular arrhythmia burden on outpatient remote monitoring that would prompt consideration for VT ablation in patients with normal LV function and mild symptoms?
The concern in this circumstance is the risk of the patient developing a PVC-meditated cardiomyopathy. It is clear that a subset of patients with a high burden of PVCs can be at risk for the development of left ventricular dysfunction. We also have data to show that reduction in the PVC burden for t...